Pharmaceutical compositions and methods utilizing neostigmine and a nk-1 antagonist for treating myasthenia gravis

ABSTRACT

The present invention describes the use of a NK1-antagonist, in constant combination with neostigmine, to facilitate the treatment of a patient suffering from myasthenia gravis by providing a therapeutically effective neostigmine bromide or methylsulfate daily dose without the dose-limiting gastrointestinal adverse effects.

RELATED APPLICATIONS

This application is a continuation of PCT/US2018/043391 (published asWO/2019/023175), filed Jul. 24, 2018, and claims the benefit of U.S.Provisional Patent Application Ser. No. 62/536,680, filed on 25 Jul.2017, and of U.S. Provisional Patent Application Ser. No. 62/695,497,filed 9 Jul. 2018, the disclosures of which are incorporated herein intheir entirety by reference.

FIELD OF THE INVENTION

This invention pertains to the field of the treatment of myastheniagravis and other myasthenic syndromes in patients suffering from thisdisease. The invention describes new compositions, methods, andcombinations for safely treating myasthenia gravis.

OBJECTS OF THE INVENTION

The present invention provides new compositions, methods, andcombinations to enable the safe administration of neostigmine tomammalian subjects with myasthenic syndromes, including myastheniagravis, which comprise administering to a patient in need of saidtreatment an effective daily dose of a NK1-antagonist in combinationwith an effective daily dose of a pharmaceutically acceptable salt ofneostigmine.

Definitions

“MG”: Myasthenia Gravis. MG is a chronic neuromuscular autoimmunedisease, characterized by muscle weakness. The basic abnormality in MGis a reduction in the acetylcholine nicotinic receptors (AChRs) atneuromuscular junctions due to the effects of autoantibodies. About 85%of patients with generalized MG have antibodies to AChRs. Antibodies toother proteins at the neuromuscular junction are present in some casesof MG, such as antibodies to muscle-specific kinase, or to low densitylipo-protein 4, or to agrin.

“Myasthenic syndrome”: refers to conditions associated with muscleweakness in which the cholinergic transmission at the neuromuscularjunction is decreased either because of a decrease in the number and/ordysfunction of post-synaptic nicotinic receptors or to a decrease in theamount of acetylcholine (“Ach”) available at the neuromuscular junctiondue to gene mutations in the presynaptic proteins involved in thesynthesis, storage and release of ACh, or to degeneration of cholinergicnerves that innervate muscles. An emerging myasthenic syndrome (with orwithout auto antibodies to nicotinic receptors) has been reported inassociation with immune-therapies used for the treatment of certainmalignancies. Myasthenic syndromes are sometimes loosely referred to asMG in the medical literature but herein, all MG-like conditions which donot involve autoantibodies to nicotinic receptors will be referred to asmyasthenic syndromes. MG itself is a myasthenic syndrome and isconsidered as such herein, although, as the most prominent myasthenicsyndrome it is often mentioned specifically (as in the phrase “MG andother myasthenic syndromes”).

“NK1-antagonist”: an antagonist of the neurokinin receptor subtype-I, inthe literature also referred to as NK1 receptor antagonist or NK1receptor inhibitor.

“Effective daily dose of NK1-antagonist”: as used herein, refers to adaily dose of said NK1-antagonist of from 1 μg to 600 mg.

“Neostigmine”: unless otherwise specified, this term, as used herein,refers to a pharmaceutically acceptable salt of neostigmine(“neostigmine pharmaceutically acceptable salt”), the daily doses andthe amounts per unit form thereof being expressed as equivalents ofneostigmine bromide per oral unit forms, and equivalents of neostigminemethylsulfate per injectable unit forms.

“Effective daily dose of neostigmine”: this expression, as used herein,refers to a neostigmine pharmaceutically acceptable salt daily dose,including doses used in the titration period, equivalent to at least 15mg of neostigmine bromide administered orally or to at least 0.5 mg ofneostigmine methylsulfate administered parenterally.

“Maximally effective (daily) dose” or “Maximal effective (daily) dose”,as used herein for neostigmine, refers to any neostigmine daily doseallowing the expression of significantly greater neostigmine efficacy,heretofore hindered by the typical gastro-intestinal neostigmine adverseeffects.

“Effective amount per unit form”, referring to neostigmine, is aneostigmine amount per unit form equivalent to at least 0.2 mg ofneostigmine methylsulfate in a parenteral 1 ml-solution unit form or asreleased from a transdermal drug delivery system; or a neostigmineamount per unit form equivalent to at least 15 mg of neostigmine bromidein an oral unit form.

“Neostigmine bromide” or “neostigmine methylsulfate”: these expressions,or equivalent ones, as used herein in connection with neostigmine doses,refer to a neostigmine dose per unit form or to a neostigmine daily dose(range) equivalent to either neostigmine bromide, in the case of an oraldose, or to neostigmine methylsulfate, in the case of a parenteral dose.

“Mammal” or “mammalian subject” as used herein refers to any class ofwarmblooded higher vertebrates (such as placentals, marsupials, ormonotremes) that nourish their young with milk secreted by mammaryglands, have the skin usually more or less covered with hair; andinclude, but are not limited to, a human, a dog, and a cat.

BACKGROUND OF THE INVENTION

Myasthenia gravis (MG) is a chronic autoimmune disease of theneuromuscular junction (NMJ) caused by antibodies that attack componentsof the postsynaptic membrane, impair neuromuscular transmission, andlead to varying degrees of weakness and fatigue of skeletal muscle. Theprevalence of MG in the United States is estimated at 14 to 20 per100,000 population, with approximately 36,000 to 60,000 cases in theUnited States (Howard, 2015). However, MG remains underdiagnosed and theprevalence is probably higher. The disease has also been described indogs, and cats (Shelton, 2016).

The hallmark of the disease is muscle weakness that increases duringperiods of activity and improves after periods of rest. Muscularweakness can be generalized or localized to certain muscle groups, andinvolvement of the bulbar and respiratory muscles can be lifethreatening (Phillips and Vincent, 2016). Groups of muscles are ofteninvolved in typical patterns. Certain muscles such as those that controleye and eyelid movement, facial expression, chewing, talking, andswallowing are often, but not always, involved in the disorder. Themuscles that control breathing and neck and limb movements may also beaffected.

MG occurs in all ethnic groups and both genders. It most commonlyaffects young adult women (under 40) and older men (over 60), but it canoccur at any age (Myasthenia Gravis Fact Sheet; National Institute ofNeurological Disorders and Stroke, 2016). In neonatal myasthenia, thefetus may acquire immune proteins (antibodies) from a mother affectedwith myasthenia gravis. Generally, cases of neonatal MG are temporaryand the child's symptoms usually disappear within 2-3 months after birth(Myasthenia Gravis Fact Sheet; National Institute of NeurologicalDisorders and Stroke, 2016). Other children develop MG indistinguishablefrom adults. MG in juveniles is uncommon (Myasthenia Gravis Fact Sheet;National Institute of neurological Disorders and Stroke, 2016).

The basic abnormality in MG is a reduction in acetylcholine receptors(AChRs) at neuromuscular junctions due to the effects of autoantibodiesthat are directed against the AChRs in most patients, or againstneighboring proteins involved in the clustering of AChRs, such as MuSK,LRP-4, or agrin (Drachman, 2016).

The diagnosis may be missed during the early stages of the disease, anddepends on the recognition of clinical manifestations, the measurementof autoantibodies, and/or electrophysiological features (Drachman,2016).

Rarely, children may show signs of congenital myasthenia or congenitalmyasthenic syndrome (CMS). These are not autoimmune disorders, but arecaused by defective genes that produce abnormal proteins instead ofthose that normally are involved in cholinergic transmission:acetylcholinesterase (the enzyme that breaks down acetylcholine),acetylcholine receptors, and other proteins present along the musclemembrane (Engel, 2012).

In some rare cases, a myasthenic syndrome is due to bi-allelic variantsin the gene encoding the vesicular acetylcholine transporter (VAChT)located in the presynaptic terminal (O'Grady et al, 2016).). In othercases, degeneration of the nerves that innervate muscles such as occurswith aging (Lexell, 1997) leads to a myasthenic syndrome. Recently(Makarious et al, 2017), have reported on a myasthenic syndromeinvolving an emerging toxicity of checkpoint inhibitors used for thetreatment of certain malignancies. Most individuals with CMS, or with animmune-oncology therapy-related myasthenic syndrome, or with progressiveage-related degeneration of the motor neurons that innervate muscles,benefit from the same treatment as those that are effective in patientswith autoimmune MG, namely choline esterase (ChE) inhibitors (Engel2012; Abicht et al, 2003 updated in 2014).

Ocular myasthenia gravis (OMG) is a localized form of myasthenia gravisin which autoantibodies directed against acetylcholine receptors blockor destroy these receptors at the postsynaptic neuromuscular junction.The hallmark of OMG is a history of painless weakness or fatigability ofthe extraocular muscles and ptosis with normal pupillary function andvisual acuity. Clinical, laboratory, electrophysiologic, andpharmacologic tests are available for diagnosis. Treatment can beginwith symptom management; there is no cure (Smith and Lee, 2017).

The treatment of myasthenic syndromes involves treatment of the symptomsthrough the enhancement of cholinergic transmission at the neuromuscularjunction by acetylcholine esterase inhibitors (AChEIs) that do notappreciably cross the Blood-Brain-Barrier (BBB), such as neostigmine.Patients with autoimmune-related myasthenic syndromes may also benefitfrom immunotherapy to slow disease progression. Options forimmunosuppression include corticosteroids, azathioprine, mycophenolatemofetil, cyclosporine, tacrolimus, methotrexate, rituximab,cyclophosphamide, intravenous immunoglobulin, plasmapheresis, andthymectomy (Gotterer and Li, 2016).

Neostigmine treats the symptoms by retarding the enzymatic hydrolysis ofacetylcholine at cholinergic synapses, so that acetylcholineconcentrations increase at the neuromuscular junction and the effect ofacetylcholine is both increased and prolonged. Cholinesterase inhibitorshave been shown to cause considerable improvement in some patients andlittle to none in others (Howard, 2015). Strength rarely returns tonormal, possibly because of dose-limiting adverse events (diarrhea,nausea, vomiting) that preclude the use of maximally effective doses ofneostigmine.

Neostigmine bromide (Prostigmin®), iodide or methylsulfate, all of whichdo not appreciably cross the BBB, are commonly used for the treatment ofMG. No fixed dosage schedule suits all patients. Neostigmine iscommercially available as a brand or generic drug, for example as oralProstigmin, consisting of tablets comprising 15 mg neostigmine bromideand vials for parenteral injection comprising 0.5 mg of neostigminemethylsulfate, a 15 mg of neostigmine bromide oral dose being equivalentto a 0.5 mg of neostigmine methylsulfate parenteral dose.

A neostigmine bromide slow release preparation which can be taken onceevery day for treating myasthenia gravis is described in CN 102258492,the contents of which are incorporated herein in their entirety byreference.

Neostigmine is also described in combination with some plant extractsaccording to traditional Chinese medicine (CN 102552381), for treatingmyasthenia gravis.

A process for the synthesis of neostigmine iodide and neostigminemethylsulfate is disclosed in RU 2010130899, the contents of which areincorporated herein in their entirety by reference.

Neostigmine methylsulfate has been disclosed as a remedy for eyediseases, in an eye drop preparation, consisting of a neostigminemethylsulfate aqueous solution, also containing other chemicals,emulsified with an oily higher fatty acid solution obtained from oliveoil and isopropyl myristate (JPS 56104814, the contents of which areincorporated herein in their entirety by reference).

Neostigmine methylsulfate has also been disclosed, in combination withnaphazoline hydrochloride and chlorpheniramine maleate, for thetreatment of conjunctivitis (CN 105708838, the contents of which areincorporated herein in their entirety by reference).

The need for neostigmine varies from day-to-day and during the same dayin response to infection, menstruation, emotional stress, and hotweather. Gastro-intestinal adverse effects of neostigmine used to treatMG are dose-limiting and typically consist of gastrointestinalcomplaints, queasiness, loose stools, nausea, vomiting, abdominalcramps, and diarrhea (Howard, 2015).

Gastro-intestinal side effects are an important source of discomfort forthe patient, may be a source of non-compliance, or may result in theneed to decrease the daily dose of neostigmine to mitigate these sideeffects whereupon these side effects become dose-limiting. As aconsequence, efficacy is reduced.

Normally, said gastro-intestinal side effects, in particular when usingneostigmine methylsulfate intravenous injection (0.5 mg/ml vials or 1mg/ml in 10-ml multiple dose vials), are counteracted by a previous orconcurrent administration of glycopyrrolate as recommended in the labelfor injectable neostigmine (Bloxyverz Prescribing Information, revisedMay 2013).

However, the literature does not disclose how to safely treat MG withneostigmine by increasing the neostigmine doses without the undesiredgastrointestinal dose-limiting adverse effects that are inevitablyassociated to said treatment, thus creating the possibility of animprovement of the condition of patients suffering from this disablingdisease.

Thus, the problem of providing tolerable, safe, chronic treatment of MGand other myasthenic syndromes with neostigmine at high, maximallyeffective doses remains unsolved.

SUMMARY OF THE INVENTION

It has now been found that, by using a neurokinin-1 receptor antagonist,also referred to as NK1 receptor inhibitor or simply NK1-antagonist, inconstant combination with neostigmine, it is possible to treat symptomsof muscle weakness associated with MG and other myasthenic syndromes inmammalian subjects, and particularly humans, dogs, and cats, sufferingfrom myasthenia gravis and other myasthenic syndromes, by maintaining atherapeutically effective neostigmine bromide daily dose or atherapeutically effective neostigmine methylsulfate daily dose withlittle to no dose-limiting gastro-intestinal adverse effect.

In particular, the constant combination of a NK1-antagonist withneostigmine enables for the first time greater or complete efficacy ofneostigmine in the treatment of symptoms of muscle weakness associatedwith MG and other myasthenic syndromes.

Thus, the present invention provides a method for treating symptoms ofmuscle weakness associated with MG and other myasthenic syndromes, whichcomprises administering to a mammalian subject in need of said treatmenta combination of a NK1-antagonist with an effective dose of neostigmine.

Any of the NK1-antagonists disclosed in the literature may be used, inthe present invention, in combination with a dose of neostigmine that isgenerally at least as high as that of the neostigmine bromide orneostigmine methylsulfate currently used doses for treating MG, and evenmuch higher. The chronic use of this combination mitigates or eveneliminates the gastro-intestinal dose-limiting adverse effects ofneostigmine, thus enabling the safe administration of the recommended oreven higher than currently recommended dose of neostigmine (maximallyeffective dose), leading to greater efficacy and safety of neostigmine.

According to the present invention, preferably, the NK1-antagonists usedare those shown to be effective for preventing or treating nausea andvomiting following cancer chemotherapy. In fact, surprisingly,NK1-antagonists, known to block nausea, vomiting, and diarrhea inducedby chemotherapeutic drugs, have been shown, in particular whenadministered at high doses, to also block the gastro-intestinal sideeffects of neostigmine without affecting its efficacy in treatingsymptoms of muscle weakness associated with MG or other myasthenicsyndromes, thus allowing the administration of neostigmine maximallyeffective doses.

This finding is surprising also because, notwithstanding the gravity ofthe illness and the fact that both neostigmine and the NK1-antagonistswere two families of products in use during more than a decade, each inits own indication, to date nobody thought that, by combining aneffective dose of NK1-antagonist with an effective dose of neostigmine,it would have been possible to safely improve the conditions of patientssuffering from MG and other myasthenic syndromes.

Thus, the present invention provides a method for treating symptoms ofmuscle weakness associated with MG and other myasthenic syndromes, whichcomprises administering to mammalian subjects, and in particular,humans, dogs, and cats, in need of said treatment an effective dailydose of a NK1-antagonist in combination with an effective daily dose ofa pharmaceutically acceptable salt of neostigmine.

According to an embodiment, the invention provides a pharmaceuticalcombination comprising a NK1-antagonist, at a daily dose that is atleast as high as the pediatric or adult dose shown to be effective forthe prevention or treatment of chemotherapy-induced nausea and vomiting,and a maximally effective dose of a neostigmine pharmaceuticallyacceptable salt.

According to another embodiment, the invention provides aNK1-antagonist, in a pharmaceutical composition comprising, as an activeingredient, said NK1-antagonist in an amount at least as high as thepediatric or adult dose shown to be effective for the prevention ortreatment of chemotherapy-induced nausea and vomiting, in admixture witha pharmaceutical carrier, for use for preventing or attenuating thedose-limiting gastrointestinal adverse effects of neostigmine in thetreatment of symptoms of muscle weakness associated with MG and othermyasthenic syndromes in a mammalian subject in need of said treatment.

According to a further embodiment, the invention includes the use of aNK1-antagonist for the preparation of a medicament including apharmaceutical composition comprising, as an active ingredient, saidNK1-antagonist, in an amount per unit form at least as high as thepediatric or adult dose shown to be effective for the prevention ortreatment of chemotherapy-induced nausea and vomiting (effective amountper unit form), in admixture with a pharmaceutical carrier, forattenuating or even abrogating the gastrointestinal adverse effects ofneostigmine in the treatment of symptoms of muscle weakness associatedwith MG and other myasthenic syndromes, in a mammalian subject in needof said treatment.

As set forth above, the amount per unit form of the NK1-antagonist is atleast as high as the pediatric or adult dose shown to be effective forthe prevention or treatment of chemotherapy-induced nausea and vomitingand may be up to 4 times and even up to 6 times said dose.

Said composition comprising said NK1-antagonist for the first timeallows the safe administration of currently used effective doses andalso higher, maximally effective neostigmine doses to mammalian subjectssuffering from symptoms of muscle weakness associated with MG or othermyasthenic syndromes, with the consequent expression of the neostigminegreater efficacy.

In particular, said composition comprising said NK1-antagonist allowsthe safe administration of

-   -   oral neostigmine daily, maximally effective dose equivalent to        from 375 mg to 1500 mg, of neostigmine bromide; and    -   parenteral, normally subcutaneous, maximally effective infusion        over 24 hours (“24 h-infusion”) neostigmine doses equivalent to        from 10 mg to 500 mg of neostigmine methylsulfate.

According to yet a further embodiment, the invention provides apharmaceutical fixed-dose combination including a pharmaceuticalcomposition in dosage unit form comprising a NK1-antagonist, in anamount per unit form that is at least as high as the pediatric or adultdose shown to be effective for the prevention and treatment ofchemotherapy-induced nausea and vomiting, as Component (a) and aneffective amount per unit form of a neostigmine pharmaceuticallyacceptable salt, as Component (b), in admixture with a pharmaceuticalcarrier or vehicle.

According to a preferred embodiment, the invention provides apharmaceutical combination comprising an approved NK1-antagonist, at adose that is at least as high as the pediatric or adult dose approvedfor the prevention or treatment of chemotherapy-induced nausea andvomiting, and an effective, especially maximally effective, dose of aneostigmine pharmaceutically acceptable salt.

According to an aspect of this preferred embodiment, the inventionprovides an approved NK1-antagonist, in a pharmaceutical compositioncomprising, as an active ingredient, said NK1-antagonist in an amount atleast as high as the pediatric or adult dose approved for the preventionor treatment of chemotherapy-induced nausea and vomiting, in admixturewith a pharmaceutical carrier, for use for preventing, attenuating oreven abrogating the gastrointestinal adverse effects of neostigmine inthe treatment of myasthenia gravis and other myasthenic syndromes.

According to a further aspect of this preferred embodiment, theinvention includes the use of an approved NK1-antagonist for thepreparation of a medicament consisting of a pharmaceutical compositioncomprising, as an active ingredient, said NK1-antagonist, in an amountat least as high as the pediatric or adult dose approved for theprevention or treatment of chemotherapy-induced nausea and vomiting, inadmixture with a pharmaceutical carrier, for preventing, attenuating oreven abrogating the gastrointestinal adverse effects of neostigmine inthe treatment of myasthenia gravis and other myasthenic syndromes.

According to yet a further aspect of this preferred embodiment, theinvention provides a pharmaceutical fixed-dose combination comprising apharmaceutical composition comprising a NK1-antagonist, in an amount perunit form that is at least as high as the pediatric or adult doseapproved for the prevention and treatment of chemotherapy-induced nauseaand vomiting, as Component (a) and an effective amount per unit form ofa neostigmine pharmaceutically acceptable salt, as Component (b), inadmixture with a pharmaceutical carrier or vehicle.

As set forth above, the amount of the NK1-antagonist is at least as highas the pediatric or adult dose approved for the prevention or treatmentof chemotherapy-induced nausea and vomiting and may be up to 6 timessaid dose.

Among the approved NK1-antagonists to be used in combination, includingfixed-dose combinations, with neostigmine, aprepitant andpharmaceutically acceptable salts and solvates and prodrugs thereof,rolapitant and pharmaceutically acceptable salts and solvates thereof,and netupitant and pharmaceutically acceptable salts and solvates andprodrugs thereof are particularly advantageous.

In the above combination, including fixed-dose combinations, said amountper unit form of said NK1-antagonist Component (a) in said compositionnormally is from 1 μg to 600 mg. The NK1-antagonist daily dose is from 1μg to 600 mg.

In the above combination, including fixed-dose combinations, theneostigmine Component (b) amount, per unit form including anyadministration route and titration, is equivalent to from 0.03 mg to 500mg of neostigmine bromide or methylsulfate. The neostigmine daily dose,including any administration route and titration, is equivalent to from0.2 mg to 1500 mg of neostigmine bromide or neostigmine methylsulfate.

The unit dose of neostigmine is equivalent to a range of from 0.09 mg to500 mg of neostigmine bromide or methylsulfate, including unit doses (inthe case of multidose systems) and unit forms, for their use in thetitration period.

The neostigmine oral dose per unit form, in an IR tablet, will be in arange equivalent to from 1 mg to 200 mg, preferably from 17.5 mg to 200mg, normally from 15 mg to 75 mg or from 17.5 mg to 75 mg of neostigminebromide, depending on safety and tolerability, in combination with aNK1-antagonist. Per day the dose, in neostigmine bromide, is from 0.5 mgto 1500 mg, normally from 15 mg to 1200 mg, from 15 mg to 450 mg or from15 mg to 375 mg, in combination with a NK1-antagonist.

If the NK1-antagonist is aprepitant or a pharmaceutically acceptablesalt thereof, its dose per IR unit form, will correspond to from 10 mgto 125 mg of aprepitant, in combination with neostigmine. If theNK1-antagonist is rolapitant, the dose/unit form in combination withneostigmine at the above doses/unit form, will range from 15 mg to 270mg in an IR formulation.

The effective or maximally effective dose of neostigmine, normally asmethylsulfate, administered by intravenous injection, is at least 0.03mg/kg to 0.07 mg/kg administered as an intravenous bolus, therecommended maximum total dose normally being at least 5 mg.

The present invention further provides a kit or package comprising apharmaceutical combination or pharmaceutical or veterinary compositionas described herein, and instructions for use of the same for treatmentof a MG and other myasthenic syndromes in a patient in need thereof.

DETAILED DESCRIPTION

The present invention improves the conditions of mammalian subjectssuffering from MG and other myasthenic syndromes by chronic treatmentwith neostigmine and a NK1-antagonist to said patient.

In particular, the present invention provides, according to certainaspects,

-   -   a method for safely improving the conditions or symptoms of        muscle weakness associated with of mammalian subjects,        particularly, humans, dogs, and cats, suffering from MG or other        myasthenic syndromes by treating said subjects with a        NK1-antagonist in combination with neostigmine;    -   a NK1-antagonist, for use in the treatment of MG and other        myasthenic syndromes in combination with neostigmine;    -   the use of a NK1-antagonist for the preparation of a medicament        for the treatment of symptoms of muscle weakness associated with        MG and other myasthenic syndromes in combination with        neostigmine; and    -   a fixed-dose combination consisting of a pharmaceutical        composition in dosage unit form comprising, as active        ingredients, a NK1-antagonist Component (a) and neostigmine        Component (b).

The present invention also relates to the use of a NK1-antagonist forthe preparation of a medicament for the treatment of symptoms of muscleweakness associated with MG and other myasthenic syndromes, saidmedicament being a pharmaceutical composition in dosage unit formcomprising, as an active ingredient, said NK1-antagonist Component (a),and, as a second active ingredient, said neostigmine Component (b), inadmixture with a pharmaceutically acceptable carrier or vehicle.

The NK1-antagonist Component (a)

Any NK1-antagonist may be used for providing the safe treatment of MGand other myasthenic syndromes with normal but also with high and veryhigh maximally effective doses of neostigmine. Antagonists of the NK1receptor that are shown to be effective for the prevention or treatmentof chemotherapy-induced nausea and vomiting are particularly usefulaccording to the present invention.

The NK1-antagonist is preferably selected from the group consisting of

-   5-[[(2R,3S)-2-[(1R)-1-[3,5-bis(trifluoromethyl)phenyl]ethoxy]-3-(4-fluorophenyl)-4-morpholinyl]methyl]-1,2-dihydro-3H-1,2,4-triazol-3-one    (aprepitant); described in U.S. Pat. No. 5,719,147, and in a liquid    oral formulation, in US 2017/0035774, and in an injectable emulsion    in a single-dose vial for intravenous use containing 130 mg    aprepitant in 18 ml of emulsion (Cinvanti®), described in U.S. Pat.    No. 9,808,465 (the contents of each disclosure is incorporated    herein in its entirety by reference);-   [3-{[(2R,3S)-2-[(1R)-1-[3,5-bis(trifluoromethyl)phenyl]ethoxy]-3-(4-fluorophenyl)morpholin-4-yl]methyl}-5-oxo-2H-1,2,4-triazol-1-yl]phosphonic    acid (fosaprepitant), disclosed, for example as dimeglumine salt in    in U.S. Pat. No. 5,691,336 and as di(cyclohexylamine) salt in US    2016/355533 (the contents of each disclosure are incorporated herein    in their entirety by reference);-   (2S,4S)-4-(4-Acetyl-1-piperazinyl)-N-[(1R)-1-[3,5-bis(trifluoromethyl)phenyl]ethyl]-2-(4-fluoro-2-methylphenyl)-N-methyl-1-piperidinecarboxamide    (casopitant) described in U.S. Pat. No. 7,294,630 (the contents of    each disclosure are incorporated herein in their entirety by    reference);-   (2S)-1-[(3aS,4S,7aS)-4-hydroxy-4-(2-methoxyphenyl)-7,7-diphenyl-1,3,3a,5,6,7a-hexahydroisoindol-2-yl]-2-(2-methoxyphenyl)propan-1-one    (INN: dapitant);-   (2S,3S)—N-(5-tert-Butyl-2-methoxybenzyl)-2-(diphenylmethyl)-1-azabicyclo[2.2.2]octan-3-amine    (maropitant, disclosed in U.S. Pat. No. 5,807,867, WO2005/082416 and    EP 3173071) (the contents of each disclosure are incorporated herein    in their entirety by reference);-   (2S,3S)-2-Diphenylmethyl-3-[(5-isopropyl-2    methoxybenzyl)amino]quinuclidine (ezlopitant), disclosed by    Evangelista S (2001). “Ezlopitant. Pfizer”; Current Opinion in    Investigational Drugs: 2 (10): 1441-3; reviewed in Drugs: the    Investigational Drugs Journal 6 (8): 758-72 (the contents of each    disclosure are incorporated herein in their entirety by reference);-   (2S)—N-{2-[3,5-bis(trifluoromethyl)phenyl]ethyl}-2-[4-(cyclopropylmethyl)piperazin-1-yl]-N-methyl-2-phenylacetamide    (INN figopitant);-   N-[(2R)-1-[Acetyl-[(2-methoxyphenyl)methyl]    amino]-3-(1H-indol-3-yl)propan-2-yl]-2-(4-piperidin-1-ylpiperidin-1-yl)acetamide    (lanepitant);-   2-[3,5-bis(trifluoromethyl)phenyl]-N,2-dimethyl-N-[4-(2-methylphenyl)-6-(4-methyl-1-piperazinyl)-3-pyridinyl]propanamide    (netupitant) described in U.S. Pat. Nos. 6,297,375, 6,719,996 and    6,593,472, and, in an oral composition, comprising 300 mg of    netupitant and palonosetron hydrochloride in an amount equivalent to    0.5 mg of palonosetron base, herein below referred to as    “netupitant-300/palonosetron’-0.5, described in U.S. Pat. No.    8,951,969 (the contents of each disclosure are incorporated herein    in their entirety by reference);-   {4-[5-{2-[3,5-bis(trifluoromethyl)phenyl]-N,2-dimethylpropanamido}-4-(2-methylphenyl)pyridin-2-yl]-1-methylpiperazin-1-ium-1-yl}methyl    hydrogen phosphate (INN: fosnetupitant), described in WO 2013/082102    and, in a pure crystalline form, in US 2017/0096442, available in an    injectable composition, comprising 235 mg of fosnetupitant and    palonosetron hydrochloride in an amount equivalent to 0.25 mg of    palonosetron base (Akynzeo® for injection), herein below referred to    as “netupitant-235palonosetron-0.25” (the contents of each    disclosure are incorporated herein in their entirety by reference);-   (2R,4S)-4-[(8aS)-6-oxo-1,3,4,7,8,8a-hexahydropyrrolo[1,2-a]pyrazin-2-yl]-N-[(1R)-1-[3,5-bis(trifluoromethyl)phenyl]ethyl]-2-(4-fluoro-2-methylphenyl)-N-methylpiperidine-1-carboxamide    (orvepitant);-   (5S,8S)-8-({(1R)-1-[3,5-bis(trifluoromethyl)phenyl]ethoxy}methyl)-8-phenyl-1,7-diazaspiro[4.5]decan-2-one    (rolapitant), described in U.S. Pat. No. 7,049,320 and, for an    injectable form thereof, in U.S. Pat. No. 9,101,615 (the contents of    each disclosure are incorporated herein in their entirety by    reference);-   3-((3aR,4R,5S,7aS)-5-[(1R)-1-[3,5-bis(trifluoromethylphenyl]ethoxy]-4-(4-fluorophenyl)-1,3,3a,4,5,6,7,7a-octahydroisoindol-2-ylcyclopent-2-en-1-one    (serlopitant) described in U.S. Pat. Nos. 7,544,815 and 7,217,731    (the contents of each disclosure are incorporated herein in their    entirety by reference);-   2-(S)-(4-Fluoro-2-methyl-phenyl)-piperazine-1-carboxylic acid    [1-(R)-(3,5-bis-trifluoromethyl-phenyl)-ethyl]-methyl-amide    (vestipitant), described in WO 2001/25219 and, in intravenous    formulation having a reduced tendency to cause hemolysis, in WO    2012/175434 (the contents of each disclosure are incorporated herein    in their entirety by reference); and-   (2S,3S)—N-[(2-methoxy-5-[5-(trifluoromethyl)tetrazol-1-yl]phenylmethyl]-2-phenylpiperidin-3-amine    (GR2015171, vofopitant), described in U.S. Pat. No. 5,703,240 (see    also U.S. Pat. No. 8,093,268) and also disclosed by Gardner C J et    al. RegulPept. 1996 Aug. 27; 65(1):45-53 (the contents of each    disclosure are incorporated herein in their entirety by reference).

Preferably, said NK1-antagonist is selected from the group consisting ofaprepitant and pharmaceutically acceptable salts, solvates and prodrugsthereof.

Illustrative examples of pharmaceutically acceptable salts of basicadvantageous NK1-antagonists include acid addition salts with mineral ororganic acids such as hydrochloric acid, hydrobromic acid, hydriodicacid, sulfuric acid, sulfamic acid, nitric acid, carbonic acid,phosphoric acid, formic acid, acetic acid, propionic acid, stearic acid,oxalic acid, malonic acid, succinic acid, fumaric acid, maleic acid,hydroxymaleic acid, lactic acid, malic acid, tartaric acid, citric acid,ascorbic acid, phenylacetic acid, benzoic acid, salicylic acid,2-acetoxybenzoic acid, methanesulfonic acid, ethanesulfonic acid,2-hydroxyethanesulfonic (isethionic) acid, p-toluenesulfonic acid,2-naphthalenesulfonic acid, 4-amino-benzenesulfonic (sulfanilic) acid,2,6-naphthalenedisulfonic acid, 1,5-naphthalenedisulfonic acid, asparticacid, glutamic acid and pamoic (embonic) acid. Said salt may be solvatedwith a solvent, said solvent normally being water.

Illustrative examples of pharmaceutically acceptable salts of acidicNK1-antagonists such as fosaprepitant include salts with inorganic basessuch as alkaline metal or alkaline-earth metal salts, and salts withorganic bases such as dicyclohexylamine salts, N-methyl-D-glucamine(meglumine) salts, and salts with amino acids, as described in U.S. Pat.No. 5,691,336, the contents of which is incorporated herein in itsentirety by reference. Aprepitant, fosaprepitant meglumine,fosaprepitant di(cyclohexylamine), rolapitant, rolapitant hydrochloride,netupitant-300/palonosetron-0.5 and fosnetupitant-235/palonosetron-0.25are particularly advantageous NK1-antagonists.

Fosaprepitant, fosaprepitant meglumine, and fosaprepitantdi(cyclohexylamine), are prodrugs of aprepitant, and fosnetupitant is aprodrug of netupitant. Thus, the expressions “fosaprepitant andpharmaceutically acceptable salts and solvates and prodrugs thereof and“netupitant and pharmaceutically acceptable salts and solvates andprodrugs thereof include aprepitant, fosaprepitant, fosaprepitantmeglumine, fosaprepitant di(cyclohexylamine), and, respectively,netupitant and fosnetupitant.

Antagonists of the NK1 receptor that are approved for the prevention ortreatment of postoperative nausea and vomiting or for the prevention ofchemotherapy-induced nausea and vomiting are particularly usefulaccording to the present invention. In particular, aprepitant iscommercially available (Emend®) in capsules containing 40 mg, 80 mg, or125 mg aprepitant, in one 150-mg powder in single-dose glass vial, forreconstitution for intravenous injection, or, as fosaprepitantdimeglumine (Emend® Injection, Ivemend®), in vials containing 115 mg or150 mg fosaprepitant; rolapitant is available (Varubi®) in 90-mgtablets; and netupitant-300/palonostron-0.5, available (Akynzeo®) in afixed-dose combination in capsules containing 300 mg of netupitant and0.5 mg of the NK1-antagonist palonosetron (as hydrochloride); andfosnetupitant-235/palonosetron-0.25 mg, available (Akynzeo® forinjection) in single-dose vial for reconstitution for intravenousinjection, are particularly advantageous NK1-antagonists.

Aprepitant and pharmaceutically acceptable salts and solvates andprodrugs thereof; rolapitant and pharmaceutically acceptable salts andsolvates thereof; and netupitant and pharmaceutically acceptable saltsand solvates and prodrugs thereof are particularly advantageousNK1-antagonists in the combination of the present invention.

More particularly, in said combination, said NK1-antagonist is selectedfrom the group consisting of aprepitant and pharmaceutically acceptablesalts and solvates thereof, at a daily dose equivalent to from 10 mg to250 mg of aprepitant; fosaprepitant and pharmaceutically acceptablesalts and solvates thereof, at a daily dose equivalent to from 10 mg to250 mg of aprepitant; rolapitant and pharmaceutically acceptable saltsand solvates thereof, at a daily dose equivalent to from 15 mg to 270 mgof rolapitant, netupitant and pharmaceutically acceptable salts andsolvates thereof, at a daily dose equivalent to from 300 mg to 600 mg;netupitant-300/palonosetron-0.5 once a day; andfosnetupitant-235/palonosetron-0.25 once a day.

For its administration to a patient suffering from MG or a myasthenicsyndrome, in combination with neostigmine, each of the aboveNK1-antagonists is formulated in a pharmaceutical composition in dosageunit form comprising, as an active ingredient, said NK1-antagonist, inadmixture with a pharmaceutical carrier or vehicle.

In particular, said NK1-antagonist active ingredient of saidpharmaceutical composition is selected from the group consisting ofaprepitant and pharmaceutically acceptable salts and solvates thereof,in an amount, per unit form, equivalent to from 10 mg to 250 mg ofaprepitant; fosaprepitant and pharmaceutically acceptable salts andsolvates thereof, in an amount, per unit form, equivalent to from 10 mgto 250 mg of aprepitant; rolapitant and pharmaceutically acceptablesalts and solvates thereof, in an amount, per unit form, equivalent tofrom 15 mg to 270 mg of rolapitant; netupitant and pharmaceuticallyacceptable salts and solvates thereof, in an amount, per unit form,equivalent to from 300 mg to 600 mg of netupitant; fosnetupitant andpharmaceutically acceptable salts and solvates thereof;netupitant-300/palonosetron-0.5; andfosnetupitant-235/palonosetron-0.25.

Advantageously, said NK1-antagonist is aprepitant, in an amount per unitform of from 10 mg to 250 mg; fosaprepitant meglumine, in an amount perunit form equivalent to from 10 mg to 250 mg of aprepitant; orrolapitant, in an amount per unit form of from 15 mg to 270 mg or from30 mg to 270 mg.

As set forth above, by using a NK1-antagonist in combination withneostigmine, it is possible to treat a patient suffering from MG or amyasthenic syndrome by maintaining a therapeutically effectiveneostigmine daily dose with minimal adverse effect.

Thus, in order to assure a sure, safe and concurrent administration ofsaid NK1-antagonist and neostigmine, the present invention provides afixed-dose combination consisting of a pharmaceutical composition indosage unit form comprising an effective amount per unit form of saidNK1-antagonist and an effective amount per unit form of saidneostigmine, in admixture with a pharmaceutical carrier or vehicle.

These NK1-antagonist/neostigmine fixed-dose combinations are illustratedin “The Fourth aspect of the invention” section below.

The Neostigmine Component (b)

Neostigmine is currently indicated for the oral treatment of MG, asneostigmine bromide, in particular in 15-mg tablets for IRadministration; and, as parenteral treatment for the reversal of theeffects of non-depolarizing neuromuscular blocking agents (NMBAs) aftersurgery as neostigmine methylsulfate, in 0.5 mg/ml and 1 mg/ml in 10 mlmultiple-dose vials.

According to the FDA approved label for oral neostigmine for thetreatment of MG, in order to have a more complete response to saidtreatment, neostigmine bromide oral doses up to 375 mg/day should beadministered. However, as set forth above, said doses are not toleratedin most patients.

Higher neostigmine doses than the currently recommended doses shouldprovide further improvement and even a near-to-complete response, i.e.,the complete alleviation of symptoms.

According to the present invention, by constantly combining (with aconcurrent administration) neostigmine bromide or neostigminemethylsulfate with a NK1-antagonist, said treatment becomes safe, andgreatly increased effective oral doses, up to 1500 mg/day, and evenmore, or parenteral doses up to 240 mg/day, and even higher, up to 500mg/day by continuous 24 h-infusion, may be attained without appreciablegastrointestinal adverse effects.

Thus, according to the present invention, for the treatment of symptomsof muscle weakness associated with MG and other myasthenic syndromes ina mammalian subject, neostigmine is formulated in unit forms, in anamount per unit form, including forms for any administration route andfor titration, equivalent to from 0.03 mg to 500 mg of neostigminebromide or methylsulfate. The neostigmine daily dose for this treatmentin combination with a NK1-antagonist, including any administration routeand titration, is equivalent to from 0.2 mg to 1500 mg of neostigminebromide or neostigmine methylsulfate.

In general, in combination with a NK1-antagonist, a pharmaceuticallyacceptable salt of neostigmine is administered at a unit dose equivalentto from 0.03 mg/kg to 6.25 mg/kg of neostigmine bromide or neostigminemethylsulfate. This unit dose includes an oral unit form comprising anamount of said neostigmine equivalent to from 0.2 mg to 200 mg ofneostigmine bromide and a parenteral unit form comprising an amount ofsaid neostigmine equivalent to from 0.09 mg to 500 mg of neostigminemethylsulfate.

It is hereby specified that, in the particular case of the subcutaneouscontinuous 24-infusion route, the term “unit dose” is intended as both aunit form and daily dose.

In combination with a NK1-antagonist, neostigmine is administered to amammal at a unit dose, including titration doses, equivalent to from0.25 mg/kg to 2.5 mg/kg of body weight of neostigmine bromide by oralroute or equivalent to from 0.03 mg/kg to 6.25 mg/kg, normally from 0.03mg/kg to 4 mg/kg of body weight of neostigmine methylsulfate byparenteral route.

In particular embodiments, the parenterally administered neostigmineunit dose is equivalent to from 0.03 mg/kg to 0.28 mg/kg of neostigminemethylsulfate by intravenous bolus injection and from 0.03 mg/kg to 8.33mg/kg, normally from 0.2 mg/kg to 4 mg/kg of neostigmine methylsulfateby subcutaneous continuous 24 h-infusion.

More particularly, for the administration by oral route, the neostigmineoral unit dose normally corresponds to a unit form comprising saidneostigmine in an amount per unit form equivalent to from 1 mg to 200 mgof neostigmine bromide;

-   -   for the administration by subcutaneous, continuous infusion (“24        h-infusion”) route, neostigmine is in a parenteral unit dose        equivalent to from 0.16 mg/24 hours (“mg/24 h”) to 500 mg/24 h        of neostigmine methylsulfate; and    -   for the administration by bolus intravenous route, neostigmine        is in a unit form (ampoule or vial) comprising a parenteral unit        dose corresponding to a unit form comprising a neostigmine        amount equivalent to from 0.09 mg/kg to 0.28 mg/kg of        neostigmine methylsulfate.

The amount of neostigmine, normally as bromide, in an oral ImmediateRelease (“IR”) unit form (“amount per unit form”) will range from 1 mgto 200 mg, normally from 15 mg to 200 mg, advantageously from 17.5 mg to200 mg, from 35 mg to 200 mg, from 45 mg to 200 mg, from 62.5 mg to 200mg, from 70 mg to 200 mg, or from 100 mg to 200 mg, depending on safetyand tolerability (per day the oral dose is from 15 mg to 1500 mg, andeven more, normally from 17.5 mg to 1500 mg, from 17.5 mg to 1125 mg,from 17.5 mg to 750 mg, or from 17.5 mg to 375 mg). One appropriateneostigmine bromide IR-tablet or IR-capsule comprises 3 mg, 8 mg, 15 mg,17.5 mg, 35 mg, 50 mg, 62.5 mg, 70 mg, 100 mg, or 200 mg of neostigminebromide.

Thus, the present invention provides appropriate unit forms, normally apharmaceutical composition in tablets or capsules comprising, as anactive ingredient, a pharmaceutically acceptable salt of neostigmine, inan amount per unit form equivalent to from 17.5 mg to 200 mg, from 35 mgto 200 mg, from 50 mg to 200 mg, from 62.5 mg to 200 mg, from 70 mg to200 mg or from 100 mg to 200 mg of neostigmine bromide, in admixturewith a pharmaceutical carrier or vehicle. Said unit forms may be safelyadministered to a mammalian subject suffering from symptoms of muscleweakness associated with MG and other myasthenic syndromes, constantlyand concurrently with a NK1-antagonist. Tablets each comprising aneostigmine pharmaceutically acceptable salt in an amount per tabletequivalent to 17.5 mg, 35 mg, 50 mg, 62.5 mg, 70 mg, 100 mg and 200 mgof neostigmine bromide are particularly appropriate.

Said unit forms are given several times per day at given intervalsdepending on the patient's response. The normal, maximally effectiveneostigmine oral daily dose is equivalent to from more than 375 mg to1200 mg/day, preferably from 450 mg to 1200 mg/day, of neostigminebromide, but some patients may need more (up to 1500 mg or more) andsome may need less.

In particular, such an oral unit form is destined to be administeredfrom two to seven times per day to mammalian subjects, and particularly,humans, dogs, and cats, suffering from conditions or symptoms of muscleweakness associated with MG or other myasthenic syndromes, incombination with a NK1-antagonist.

In the case of administration of high doses, two unit forms may besimultaneously administered from two to seven times per day to saidmammalian subjects in combination with a NK1-antagonist. In this case,the unit dose thus administered does not correspond to a unit form.

For the continuous 24-hour/day subcutaneous neostigmine infusion, themaximally effective daily dose in combination with a NK1-antagonist isequivalent to from 0.2 mg (to neonates) daily to 500 mg daily ofneostigmine methylsulfate. Said infusion is in unit doses normallycorresponding to the 24-hour dose, preferably in unit doses comprisingan amount of neostigmine equivalent to from 0.2 mg to 10 mg, from 10 mgto 50 mg, from 50 mg to 100 mg, from 100 mg to 150 mg, from 150 mg to200 mg, from 200 mg to 250 mg, from 250 mg to 300 mg, from 300 mg to 350mg, from 350 to 400 mg, from 400 mg to 450 mg or from 450 mg to 500 mgof neostigmine methylsulfate.

When administered by continuous subcutaneous injection, neostigminemethylsulfate is normally administered at single ampoule doses of from0.09 mg (to neonates) to 500 mg, to be administered once every 24 hoursin order to supply a maximally effective daily dose of from 1 mg(neonates) to 500 mg.

A safer administration is assured by combining, in the same oral unitform, a NK1-antagonist, in an amount per oral unit form of from 1 μg to600 mg; and neostigmine, in an amount per unit form equivalent to from0.2 mg to 200 mg, normally from 15 mg to 200 mg, advantageously from17.5 mg to 200 mg of neostigmine bromide.

In combination with a NK1-antagonist, the effective neostigmine dailydose-range for the treatment of a myasthenic syndrome in a mammal,including parenteral (intravenous, intravenous infusion, subcutaneous,subcutaneous infusion, transcutaneous or intramuscular), oral and otheradministration means as illustrated in “The formulations” section below,is normally equivalent to from 2 mg to 1500 mg, and even more, ofneostigmine bromide or neostigmine methylsulfate.

Preferably, said NK1-antagonist is one of the approved NK1-antagonistsdescribed in “The NK1-antagonist” section, in an amount per unit form asdescribed in the same section and said neostigmine is neostigminebromide or neostigmine methylsulfate.

First Aspect of the Invention

According to a first aspect, the present invention provides a method forsafely improving the conditions of mammalian subjects, particularly,humans, dogs, and cats, suffering from symptoms of muscle weaknessassociated with MG or another myasthenic syndrome, comprisingchronically administering to said mammalian subjects a NK1-antagonist incombination with neostigmine.

In particular, the present invention describes a method for safelyimproving the conditions of a human patient suffering from MG or othermyasthenic syndromes and treated with neostigmine by chronicallyadministering to said patient a NK1-antagonist.

Any of the NK1-antagonists illustrated in “The NK1-antagonist” sectionabove may be used for improving the conditions of a mammalian subjectsuffering from a myasthenic syndrome, in combination with neostigmine atthe currently used doses and, in particular, at heretofore intolerabledoses and even at very high doses, as illustrated in “The neostigmineComponent (b)” section above.

More particularly, the present invention provides a method for safelyimproving the conditions of a mammal suffering from symptoms of muscleweakness associated with MG and other myasthenic syndromes, whichcomprises chronically administering to said mammal a NK1-antagonist incombination with neostigmine.

In carrying out the method of the present invention, the daily dose ofthese NK1-antagonists is at least as high as that preventing or treatingnausea and vomiting in pediatric or adult patients undergoing a surgicaloperation or cancer chemotherapy according to the current protocols forsaid treatment or prevention. In particular, said daily dose is from 1μg to 600 mg, normally from 1 mg to 600 mg, or from 1 mg to 300 mg.

The NK1-antagonists allowing safe treatment with neostigmine, inparticular at heretofore intolerable doses and even at high doses, areillustrated in “The NK1-antagonist” section.

According to an embodiment,

-   -   said NK1-antagonist is selected from the group consisting of        aprepitant and pharmaceutically acceptable salts and solvates        and prodrugs thereof, rolapitant and pharmaceutically acceptable        salts and solvates and prodrugs thereof, netupitant and        pharmaceutically acceptable salts and solvates and prodrugs        thereof, each at a daily dose illustrated in “The        NK1-antagonist” section; and    -   said neostigmine is selected from the group consisting of        pharmaceutically acceptable salts of neostigmine, at a daily        dose as illustrated above in “The neostigmine Component (b)”        section.

Preferably, said NK1-antagonist is selected from the group consisting ofaprepitant and pharmaceutically acceptable salts and solvates thereof,at a daily dose equivalent to from 10 mg to 250 mg of aprepitant;fosaprepitant and pharmaceutically acceptable salts and solvatesthereof, at a daily dose equivalent to from 10 mg to 250 mg ofaprepitant; rolapitant and pharmaceutically acceptable salts andsolvates thereof, at a daily dose equivalent to from 15 mg to 270 mg ofrolapitant, netupitant and pharmaceutically acceptable salts andsolvates thereof, at a daily dose equivalent to from 300 mg to 600 mg;netupitant-300/palonosetron-0.5 once a day; andfosnetupitant-235/palonosetron-0.25 once a day.

The above daily doses of the above NK1-antagonists allow the safeadministration to a mammal of currently used neostigmine daily doses andeven of high and very high neostigmine daily doses.

In particular, the above daily doses of said NK1-antagonist allow thesafe treatment of adult human patients suffering from MG or othermyasthenic syndromes with a neostigmine oral maximally effective dailydose equivalent to from 375 mg to 1500 mg, preferably from 450 mg to1500 mg; or from 375 mg to 1200 mg, preferably from 450 mg to 1200 mg ofneostigmine bromide.

The above daily dose of NK1 antagonists also allows the safeadministration to a mammalian subject of parenteral doses ofneostigmine, normally as methylsulfate.

For example, aprepitant, at a daily dose of from 10 mg to 250 mg, allowsthe safe, continuous 24-hour/day subcutaneous neostigmine infusion, at amaximally effective neostigmine daily dose equivalent to a rangeselected from the group consisting of from 10 mg to 500 mg, from 30 mgto 500 mg, from 120 mg to 500 mg, from 30 mg to 400 mg, from 120 mg to400 mg, and from 120 mg to 240 mg of neostigmine methylsulfate.

For said treatment, said NK1-antagonist is formulated in apharmaceutical composition in dosage unit form comprising an effectiveamount per unit form of said NK1-antagonist, normally from 1 μg to 600mg, in admixture with a pharmaceutical carrier or vehicle, asillustrated in “The NK1-antagonist Component (a)” section.

Preferably, said NK1-antagonist active ingredient of said pharmaceuticalcomposition is selected from the group consisting of aprepitant andpharmaceutically acceptable salts and solvates thereof, in an amount,per unit form, equivalent to from 10 mg to 250 mg of aprepitant;fosaprepitant and pharmaceutically acceptable salts and solvatesthereof, in an amount, per unit form, equivalent to from 10 mg to 250 mgof aprepitant; rolapitant and pharmaceutically acceptable salts andsolvates thereof, in an amount, per unit form, equivalent to from 15 mgto 270 mg of rolapitant; netupitant and pharmaceutically acceptablesalts and solvates thereof, in an amount, per unit form, equivalent tofrom 300 mg to 600 mg; netupitant-300/palonosetron-0.5; andfosnetupitant-235/palonosetron-0.25.

Said NK1-antagonist and said neostigmine may also be co-formulated in apharmaceutical composition, in admixture with a pharmaceutical carrieror vehicle as illustrated in the “Fourth aspect of the invention” below.

Second Aspect of the Invention

According to a second aspect, the invention provides a NK1-antagonist,for use for the safe treatment of mammalian subjects, and particularly,humans, dogs, and cats, suffering from conditions or symptoms of muscleweakness associated with MG or other myasthenic syndromes, incombination with neostigmine. Such a treatment safely improves saidconditions or symptoms.

Any NK1-antagonist, in particular those that are shown to be effectivefor the prevention or treatment of chemotherapy-induced nausea andvomiting may be used, in a combination, including fixed-dosecombinations, with neostigmine according to this aspect of the presentinvention. Preferably, said NK1-antagonists are those approved for theprevention or treatment of chemotherapy-induced nausea and vomiting.

For its use, said NK1-antagonist is formulated in a pharmaceutical orveterinary composition in dosage unit form comprising an effectiveamount per unit form of said NK1-antagonist, in admixture with apharmaceutical carrier or vehicle.

The amounts per unit form of said NK1-antagonists and the daily doses tobe administered to a mammal such as a cat or a dog, or a human patientsuffering from symptoms of muscle weakness associated with MG or anothermyasthenic syndrome in combination with neostigmine are described in“The NK1-antagonist” section.

In particular, the NK1-antagonist is in a pharmaceutical or veterinarycomposition comprising said NK1-antagonist in an effective amount perunit form of from 1 μg to 600 mg to be normally administered to amammalian subject once a day in combination with neostigmine, also in apharmaceutical or veterinary composition in dosage unit form comprisingan effective amount per unit form of said neostigmine.

Preferably, said NK1-antagonist active ingredient of said pharmaceuticalcomposition is selected from the group consisting of aprepitant andpharmaceutically acceptable salts and solvates thereof, in an amount perunit form equivalent to from 10 mg to 250 mg of aprepitant;fosaprepitant and pharmaceutically acceptable salts and solvatesthereof, in an amount per unit form equivalent to from 10 mg to 250 mgof aprepitant; rolapitant and pharmaceutically acceptable salts andsolvates thereof, in an amount per unit form equivalent to from 15 mg to270 mg of rolapitant; netupitant and pharmaceutically acceptable saltsand solvates thereof, in an amount per unit form equivalent to from 300mg to 600 mg; netupitant-300/palonosetron-0.5; andfosnetupitant-235/palonosetron-0.25.

Said composition is for use for safely improving the conditions orsymptoms of muscle weakness associated with mammalian subjects, andparticularly, humans, dogs, and cats, suffering from MG or othermyasthenic syndromes, in combination with neostigmine.

For this treatment in combination with said NK1-antagonist composition,neostigmine is formulated in unit forms, in an amount per unit form,including forms for any administration route and for titration,equivalent to from 0.03 mg to 500 mg of neostigmine bromide ormethylsulfate. The neostigmine daily dose for this treatment incombination with a NK1-antagonist, including any administration routeand titration, is equivalent to from 0.2 mg to 1500 mg of neostigminebromide or neostigmine methylsulfate.

Said composition provides a safe treatment for MG or other myasthenicsyndromes, in combination, for example, with neostigmine daily oraldoses equivalent to from 15 mg to 1500 mg, especially of maximallyeffective daily oral doses of from 375 mg to 1500 mg, normally from 375mg to 1200 mg or from 450 mg to 1200 mg of neostigmine bromide.

Said composition also provides for the safe administration to amammalian subject of parenteral doses of neostigmine, normally asmethylsulfate, for example a continuous 24-hour/day subcutaneousneostigmine infusion, at a maximally effective daily dose equivalent tofrom 10 mg to 500 mg, advantageously from 30 mg to 400 mg, normally from120 mg to 240 mg of neostigmine methylsulfate.

For said use, the daily dose of these NK1-antagonists is at least ashigh as that preventing or treating nausea and vomiting in pediatric oradult patients undergoing a surgical operation or cancer chemotherapyaccording to the current protocols for said treatment or prevention. Inparticular, said daily dose is from 1 μg to 600 mg, normally from 1 mgto 600 mg, or from 1 mg to 300 mg.

Among the above NK1-antagonists to be used in combination, includingfixed-dose combinations, with neostigmine, aprepitant andpharmaceutically acceptable salts or solvate or prodrugs thereof,rolapitant and pharmaceutically acceptable salts or solvates thereof,netupitant and pharmaceutically acceptable salts and solvates andprodrugs thereof are particularly advantageous.

The above daily doses of the above NK1-antagonists allow the safeadministration of currently used neostigmine daily doses and even ofhigh and very high neostigmine daily doses.

In particular, the above daily doses of said NK1-antagonist allow thesafe treatment of adult patients suffering from MG or other myasthenicsyndromes with, for example, a neostigmine oral daily maximallyeffective dose equivalent to from 375 mg to 1500 mg, normally from 375mg to 1200 mg or from 450 mg to 1200 mg of neostigmine bromide.

The above daily dose of NK1 antagonists also allows the safeadministration to a mammalian subject of parenteral doses ofneostigmine, normally as methylsulfate.

For example, aprepitant, at a daily dose of from 10 mg to 250 mg, allowsa safe, continuous 24-hour/day subcutaneous neostigmine infusion at aneffective daily dose equivalent to a range selected from the groupconsisting of from 10 mg to 500 mg, from 30 mg to 500 mg, from 120 mg to500 mg, from 30 mg to 400 mg, from 120 mg to 400 mg, and from 120 mg to240 mg, of neostigmine methylsulfate.

More particularly, in said combination, said NK1-antagonist is selectedfrom the group consisting of aprepitant and pharmaceutically acceptablesalts and solvates thereof, at a daily dose equivalent to from 10 mg to250 mg of aprepitant; fosaprepitant and pharmaceutically acceptablesalts and solvates thereof, at a daily dose equivalent to from 10 mg to250 mg of aprepitant; rolapitant and pharmaceutically acceptable saltsand solvates thereof, at a daily dose equivalent to from 15 mg to 270 mgof rolapitant, netupitant and pharmaceutically acceptable salts andsolvates thereof, at a daily dose equivalent to from 300 mg to 600 mg;netupitant-300/palonosetron-0.5; andfosnetupitant-235/palonosetron-0.25.

Said NK1-antagonist and said neostigmine may also be co-formulated in apharmaceutical composition, in admixture with a pharmaceutical carrieror vehicle as illustrate herein below, in “The fourth aspect of theinvention”.

Third Aspect of the Invention

According to a third aspect, the invention provides the use of aNK1-antagonist for the preparation of a medicament for the treatment ofmammalian subjects, in particular humans, dogs, and cats, suffering fromconditions or symptoms of muscle weakness associated with MG or othermyasthenic syndromes, in combination with neostigmine. Such a treatmentsafely improves said conditions or symptoms.

This medicament for the treatment of symptoms of muscle weaknessassociated with MG and other myasthenic syndromes comprises aNK1-antagonist formulated in a pharmaceutical or veterinary compositionin dosage unit form wherein said NK1-antagonist is in admixture with apharmaceutical carrier or vehicle, to be administered, concurrently orsequentially, in combination with neostigmine.

In said pharmaceutical or veterinary composition for said treatment,said NK1-antagonist is in admixture with a pharmaceutical carrier andformulated in unit forms for oral, intravenous, transcutaneous, ortransdermal administration, as described in “The formulations” sectionbelow.

According to this third aspect of the present invention, any of theNK1-antagonists described in “The NK1-antagonist Component (a)” sectionmay be used as an active ingredient of said pharmaceutical or veterinarycomposition indicated for said treatment, in combination withneostigmine doses as described in “The neostigmine Component (b)”section.

According to an embodiment of this third aspect of the invention, saidmedicament is a pharmaceutical or veterinary composition in dosage unitform comprising, as an active ingredient, said NK1-antagonist, in anamount per unit form of from 1 μg to 600 mg, in admixture with apharmaceutical carrier or vehicle.

Said medicament, in the above dose per unit form is destined to beadministered to said mammalian subject at a daily dose of from 1 μg to600 mg, in combination with an effective daily dose of neostigmine.

Among the above NK1-antagonists to be used in combination, includingfixed-dose combinations, with neostigmine, aprepitant andpharmaceutically acceptable salts and solvates and prodrugs thereof,rolapitant and pharmaceutically acceptable salts and solvates thereof,netupitant and pharmaceutically acceptable salts and solvates andprodrugs thereof are particularly advantageous.

In particular, the medicament according to this third aspect of theinvention includes a pharmaceutical or veterinary composition comprisinga NK1-antagonist active ingredient selected from the group consisting ofaprepitant and pharmaceutically acceptable salts and solvates thereof,in an amount per unit form equivalent to from 10 mg to 250 mg ofaprepitant; fosaprepitant and pharmaceutically acceptable salts andsolvates thereof, in an amount per unit form equivalent to from 10 mg to250 mg of aprepitant; rolapitant and pharmaceutically acceptable saltsand solvates thereof, in an amount per unit form equivalent to from 15mg to 270 mg of rolapitant; netupitant and pharmaceutically acceptablesalts and solvates thereof, in an amount per unit form equivalent tofrom 300 mg to 600 mg; netupitant-300/palonosetron-0.5; andfosnetupitant-235/palonosetron-0.25.

The pharmaceutical compositions of the present invention are formulatedin unit form with the classic excipients suitable for different ways ofadministration. Particularly advantageous are the formulations in theform of tablets, multi-score tablets, coated tables, orallydisintegrating tablets, extended release tablets, hard or soft capsules,extended-release capsules, patches for transdermal administration,liquid oral solutions, syrups or suspensions in a predetermined unitform, and vials for the intravenous or subcutaneous administration.

The aforementioned pharmaceutical composition comprising saidNK1-antagonist, in the aforementioned amounts per unit form, isadministered to a patient suffering from MG or another myasthenicsyndrome in combination with neostigmine, also in a pharmaceuticalcomposition in dosage unit form, comprising an effective amount ofneostigmine in admixture with a pharmaceutical carrier. Said effectiveamounts, in unit forms for oral, intravenous, or subcutaneous forcontinuous infusion administration as well as the neostigmine dailydoses, are illustrated in “The neostigmine Component (b)” section.

Normally, said effective amount per unit form for oral administration isin the range of from 0.2 mg to 200 mg, preferably from 17.5 mg to 200mg. According to a preferred embodiment, said neostigmine is neostigminebromide. Said effective amount per unit form for continuous subcutaneousinfusion administration is from 10 mg to 500 mg, preferably from 60 mgto 240 mg. According to a preferred embodiment, said neostigmine forcontinuous subcutaneous infusion is neostigmine methylsulfate.

In said combination, said NK1-antagonist is preferably selected from thegroup consisting of aprepitant and pharmaceutically acceptable salts andsolvates thereof, administered at a daily dose equivalent to from 10 mgto 250 mg of aprepitant; fosaprepitant and pharmaceutically acceptablesalts and solvates thereof, administered at a daily dose equivalent tofrom 10 mg to 250 mg of aprepitant; rolapitant and pharmaceuticallyacceptable salts and solvates thereof, administered at a daily doseequivalent to from 15 mg to 270 mg of rolapitant; netupitant andpharmaceutically acceptable salts and solvates thereof, administered ata daily dose equivalent to from 300 mg to 600 mg of netupitant;netupitant-300/palonosetron-0.5, administered once a day; andfosnetupitant-235/palonosetron-0.25, administered once a day.

According to this third aspect of the present invention, said medicamentis destined to be administered to said mammalian subject, at the abovedaily dose, in combination with neostigmine. Preferably, saidneostigmine is neostigmine bromide for oral administration orneostigmine methylsulfate for parenteral administration.

In the treatment of symptoms of muscle weakness associated with MG andother myasthenic syndromes, the NK1-antagonist and the neostigmine areused in combination and the two active components may be co-administeredsimultaneously or sequentially, or in a fixed dose combinationcomprising a pharmaceutical composition comprising the NK1-antagonistand neostigmine, in admixture with a pharmaceutically acceptable carrieror vehicle.

As mentioned above, the NK1-antagonist Component (a) and the neostigmineComponent (b) can be administered separately or together in anyconventional oral or parenteral dosage unit form such as capsule,tablet, powder, sachet, suspension, solution, or transdermal device. Theamount of NK1-antagonist per oral unit form in preferred embodimentswill be in the range of from 1 μg to 600 mg. The amount of neostigmineper unit form in preferred embodiments will be in the range of from 1 mgto 200 mg, normally from 17.5 mg to 200 mg.

In the case of separate (concurrent or sequential) administration ofsaid NK1-antagonist, in an effective amount per unit form, and of saidneostigmine, in an effective amount per unit form, each of them can bepackaged in a kit comprising said NK1-antagonist, in admixture with apharmaceutical carrier or vehicle, in a container; and said neostigmine,in admixture with a pharmaceutical carrier or vehicle, in another,separate container.

For the concurrent administration of said NK1-antagonist and of saidneostigmine, the two active principles can be formulated together andwith a pharmaceutical carrier or vehicle, in a pharmaceuticalcomposition.

Accordingly, the present invention provides the use of a NK1-antagonistfor the preparation of a medicament for the treatment of symptoms ofmuscle weakness associated with MG and other myasthenic syndromes incombination with neostigmine, said medicament including a pharmaceuticalcomposition in dosage unit form comprising said NK1-antagonist and saidneostigmine pharmaceutically acceptable salt, in admixture with apharmaceutical carrier or vehicle.

Fourth Aspect of the Invention

According to a fourth aspect of the present invention, thepharmaceutical composition comprising a NK1-antagonist may containanother active ingredient, in particular neostigmine, co-formulated withsaid NK1-antagonist, in admixture with a pharmaceutical carrier orvehicle.

Thus, the present invention further provides a fixed-dose combinationincluding a pharmaceutical or veterinary composition in dosage unit formcomprising, as active ingredients, Component (a): a NK1-antagonist; andComponent (b): neostigmine, in admixture with a pharmaceutical carrieror vehicle.

Normally, in said composition, the NK1-antagonist Component (a) ispresent in an amount per unit form of from 1 μg to 600 mg and theneostigmine Component (b) for oral administration is present in anamount equivalent to from 0.2 mg to 200 mg, normally to from 17.5 mg to200 mg of neostigmine bromide or for subcutaneous 24-hour continuousadministration is present in an amount equivalent to 10 mg to 500 mg, or30 mg to 400 mg, preferably 60 mg to 240 mg of neostigminemethylsulfate.

Said fixed-dose combination is useful for the treatment of MG and othermyasthenic disorders in a mammal such as a cat, a dog or a human being.Said treatment safely provides said mammal with a NK1-antagonist dose offrom 1 μg to 600 mg and a single neostigmine dose equivalent to from 0.2mg to 200 mg of neostigmine bromide or neostigmine methylsulfate.

When said mammal is a human being, the above fixed-dose combination maybe safely used for the treatment of infants, including neonates, andincludes neostigmine doses for titration.

Among the above NK1-antagonists to be used in combination, includingfixed-dose combinations, with neostigmine, aprepitant andpharmaceutically acceptable salts and solvates and prodrugs thereof,rolapitant and pharmaceutically acceptable salts and solvates thereof,netupitant and pharmaceutically acceptable salts and solvates andprodrugs thereof are particularly advantageous.

According to one embodiment,

said NK1-antagonist Component (a) active ingredient is selected from thegroup consisting of aprepitant and pharmaceutically acceptable salts andsolvates thereof, in an amount, per unit form, equivalent to from 10 mgto 250 mg of aprepitant; fosaprepitant and pharmaceutically acceptablesalts and solvates thereof, in an amount, per unit form, equivalent tofrom 10 mg to 250 mg of aprepitant; rolapitant and pharmaceuticallyacceptable salts and solvates thereof, in an amount, per unit form,equivalent to from 15 mg to 270 mg of rolapitant; netupitant andpharmaceutically acceptable salts and solvates thereof, in an amount,per unit form, equivalent to from 300 mg to 600 mg of netupitant;netupitant-300/palonosetron-0.5; andfosnetupitant-235/palonosetron-0.25; and

said neostigmine pharmaceutically acceptable salt Component (b) is in anamount per unit form equivalent to from 0.2 mg to 200 mg of neostigminebromide or 10 mg to 240 mg of neostigmine methylsulfate; and

the Components are mixed together and with a pharmaceutical carrier orvehicle.

According to a first aspect of this one embodiment, the fixed-dosecombination is a pharmaceutical composition in dosage unit formcomprising a NK1-antagonist Component (a) selected from the groupconsisting of aprepitant, in an amount per unit form of from 10 mg to250 mg; and rolapitant, in an amount per unit form of from 15 mg to 270mg; and neostigmine bromide Component (b), in an amount per unit form offrom 15 mg to 200 mg, from 17.5 mg to 200 mg, from 35 mg to 200 mg, from50 mg to 200 mg, from 62.5 mg to 200 mg, from 70 mg to 200 mg and from100 mg to 200 mg, in admixture with a pharmaceutical carrier or vehiclein an oral formulation.

According to a second aspect of this one embodiment, the fixed-dosecombination is a pharmaceutical composition in dosage unit formcomprising

a NK1-antagonist Component (a) selected from the group consisting ofaprepitant, in an amount per unit form of from 25 mg to 200 mg; andfosaprepitant dimeglumine, in an amount per unit form of 25 mg to 200mg; and

neostigmine methylsulfate Component (b), in an amount per unit form offrom 0.2 mg to 200 mg, from 17.5 mg to 200 mg, from 35 mg to 200 mg,from 50 mg to 200 mg, from 62.5 mg to 200 mg, from 70 mg to 200 mg andfrom 100 mg to 200 mg,

in admixture with a pharmaceutical carrier or vehicle in a parenteralformulation for injection or infusion.

According to a second embodiment,

said Component (a) is a mixture of the NK1-antagonist netupitant, in anamount per unit form of 300 mg, and of the 5HT3-antagonist palonosetronhydrochloride, in an amount per unit form equivalent to 0.5 mg ofpalonosetron base; and

said neostigmine Component (b) is neostigmine bromide in an amount perunit form of from 15 mg to 200 mg, from 17.5 mg to 200 mg, from 35 mg to200 mg, from 50 mg to 200 mg, from 62.5 mg to 200 mg, from 70 mg to 200mg and from 100 mg to 200 mg; and

the Components are mixed together and with a pharmaceutical carrier orvehicle for oral administration.

According to a third embodiment,

said Component (a) is a mixture of the NK1-antagonist fosnetupitant, inan amount per unit form of 235 mg, and of the 5HT3-antagonistpalonosetron hydrochloride, in an amount per unit form equivalent to0.25 mg of palonosetron base; and

said neostigmine Component (b) is neostigmine methylsulfate in an amountper unit form of from 0.2 mg to 200 mg, from 17.5 mg to 200 mg, from 35mg to 200 mg, from 50 mg to 200 mg, from 62.5 mg to 200 mg, from 70 mgto 200 mg and from 100 mg to 200 mg; and

the Components are mixed together and with a pharmaceutical carrier orvehicle for parenteral administration or for reconstitution in asolution for parenteral, normally intravenous, administration.

In the above NK1-antagonist/neostigmine fixed dose combinations, theabove-illustrated pharmaceutical compositions in dosage unit form arepreferably administered to a pediatric or adult patient suffering fromsymptoms of muscle weakness associated with MG or another myasthenicsyndrome to provide a neostigmine oral daily dose equivalent to from 1mg to 1500 mg, and even more, normally from 15 mg to 1200 mg, from 17.5mg to 1200 mg, from 270 mg to 1200 mg, from 375 mg to 1200 mg,preferably from 450 mg to 1200 mg of neostigmine bromide or forcontinuous subcutaneous infusion from 10 mg to 500 mg, or 30 mg to 500mg, or 60 mg to 240 mg of neostigmine methylsulfate.

The Formulations

For the use in the treatment of symptoms of muscle weakness associatedwith MG and other myasthenic syndromes in combination with neostigmine,the NK1-antagonist is formulated in a pharmaceutical composition indosage unit form, wherein said NK1-antagonist is in admixture with apharmaceutical carrier or vehicle. For said treatment, also neostigmineis formulated in a pharmaceutical composition in dosage unit form,wherein said neostigmine is in admixture with a pharmaceutical carrieror vehicle.

These unit forms are manufactured according to conventionaltechnologies. Particularly advantageous are the formulations in the formof tablets, multi-score tablets, multi-layer tablets, coated tables,orally disintegrating tablets, extended release tablets, hard or softcapsules, multi-compartment capsules, extended-release capsules, patchesfor transdermal administration, liquid oral solutions, syrups orsuspensions in a predetermined unit form, apparatus for intravenousinfusion, and vials for the intravenous or subcutaneous administration.

As set forth above, the pharmaceutical compositions are formulated inadmixture with a pharmaceutical carrier or vehicle for anyadministration route. For example, said pharmaceutical compositions arein a pharmaceutical dosage unit form for oral, intravenous (includinginfusion), intramuscular, intranasal, intraperitoneal, subcutaneous,transdermal, or rectal administration.

“Transdermal drug delivery system” (TDDS) provides transdermal deliveryusing transdermal drug formulations and transdermal patchesincorporating such transdermal drug formulations. For example, thetransdermal drug delivery system may include a composition in form of apatch, a cream, a gel, a lotion or a paste comprising a NK1-antagonist,neostigmine or both the active ingredients.

Said unit forms are manufactured according to conventional technologies,normally as pharmaceutical compositions formulated with the classicexcipients suitable for different ways of administration. Particularlyadvantageous are the formulations in the form of tablets, multi-scoretablets, multi-layer tablets, coated tables, orally disintegratingtablets, extended release tablets, hard or soft capsules,multi-compartment capsules, extended-release capsules, patches fortransdermal administration, liquid oral solutions, syrups or suspensionsin a predetermined unit form, apparatus for intravenous infusion, andvials for the intravenous or subcutaneous administration.

Said oral forms may be tablets coated with sucrose or with variouspolymers or, alternatively, the tablets can be manufactured by usingcarriers such as acrylic and methacrylic acid polymers and copolymers;cellulose derivatives such as hydroxypropylethylcellulose; or otherappropriate materials, to have a prolonged or delayed activity byprogressively releasing a predetermined quantity of NK1-antagonist or ofneostigmine, or of both the active ingredients. The oral formulationscan also be in form of capsules allowing the extended release of theNK1-antagonist, or of neostigmine, or of both the active ingredients.

The unit forms may be formulated in tablets in which Component (b) is inExtended Release (“ER”)-formulation, for example in admixture withhydroxypropyl methyl cellulose or in a film-coated microgranule.Carriers and vehicles for ER tablets include retardant materials such asacrylic and methacrylic acid polymers and copolymers; the aforementionedcellulose derivatives such as hydroxypropylmethylcellulose,hydroxyethylcellulose, hydroxypropylethylcellulose,hydroxypropylcellulose, methylcellulose, ethylcellulose, or sodiumcarboxymethylcellulose; gums; waxes; glycerides or aliphatic alcohols ora mixture thereof.

In the combination of the present invention, each unit form may also bea vial containing the pharmaceutical composition a solution, anemulsion, a powder for reconstitution or also an apparatus forcontinuous infusion of a solution or an emulsion, wherein the activeingredient is dissolved in or mixed with a pharmaceutical carrier forparenteral use.

The pharmaceutical compositions may also be formulated in a TDDS, suchas a patch formulation wherein the active ingredient or the mixture ofthe active ingredients, for example in a matrix, may comprise adjuvantssuch as D-sorbitol, gelatin, kaolin, methyl paraben, polysorbate 80,propylene glycol, propyl paraben, povidone, sodiumcarboxymethylcellulose, sodium polyacrylate, tartaric acid, titaniumdioxide, and purified water. A patch formulation may also contain skinpermeability enhancer such as lactate esters (e.g., lauryl lactate),triacetin or diethylene glycol monoethyl ether.

In the above pharmaceutical compositions, the preferred NK1-antagonistactive ingredient is selected from the group consisting of aprepitantand pharmaceutically acceptable salts and solvates and prodrugs thereof,rolapitant and pharmaceutically acceptable salts and solvates thereof,and netupitant and pharmaceutically acceptable salts and solvates andprodrugs thereof, preferably aprepitant, fosaprepitant, rolapitant,netupitant-300/palonosetron-0.5; or fosnetupitant-235/palonosetron-0.25,and the preferred neostigmine is neostigmine bromide or neostigminemethylsulfate.

Thus, for example, a pharmaceutical composition according to the presentinvention, to be chronically administered in combination withneostigmine, comprises a NK1-antagonist selected from the groupconsisting of aprepitant and pharmaceutically acceptable salts andsolvates and prodrugs thereof, in an amount/unit form equivalent to from10 mg to 250 mg of aprepitant; rolapitant and pharmaceuticallyacceptable salts and solvates thereof, in an amount/unit form equivalentto from 30 mg to 270 mg of rolapitant; and netupitant andpharmaceutically acceptable salts and solvates and prodrugs thereof, inan amount/unit form equivalent to from 150 mg to 600 mg of netupitant.

When the NK1-antagonist and neostigmine are in a fixed-dose combinationfor oral administration, the unit form may be a stratified, bi-layertablet wherein the NK1-antagonist, formulated with a pharmaceuticalcarrier, normally in IR-formulation, is in one of the layers andneostigmine, formulated with a pharmaceutical carrier, is the otherlayer, preferably in ER-formulation. Similarly, the NK1-antagonist andneostigmine active ingredients are in a pill containing one of theactive ingredients, admixed with a pharmaceutical carrier, in the coreand the other active ingredient, admixed with a pharmaceutical carrier,is in the outer part of the pill, the core and the outer part beingoptionally separated by an inert film or carrier. Analogously, capsulesmade of two separated parts, one containing Component (a), inIR-formulation and the other containing Component (b), inER-formulation, may be manufactured.

Especially in the case of mammalian subject such as cats and dogs and ofhuman pediatric or obese human patients, the NK1-antagonist andneostigmine daily dose may be decided on the basis of the body weight.

Thus, for example, aprepitant may be administered at a daily dose of0.16 mg/kg to 4.2 mg/kg and rolapitant may be administered at a dailydose of 0.25 mg/kg to 4.5 mg/kg. The above doses are preferablyadministered by oral route.

Neostigmine may be administered at a single oral dose equivalent to from0.25 mg/kg to 2.5 mg/kg of body weight of neostigmine bromide; at asingle parenteral dose equivalent to from 0.03 mg/kg to 6.25 mg/kg,normally from 0.03 mg/kg to 4 mg/kg, of body weight of neostigminemethylsulfate.

Kits

The present invention also provides a kit or package containing amedicament, a pharmaceutical combination, or a pharmaceuticalcomposition as described herein, accompanied by instructions for use ofthe same in the treatment of symptoms of muscle weakness associated withmyasthenia gravis or another myasthenic syndrome in a mammalian subjectin need thereof.

In one embodiment, a kit of the present invention is a kit comprising acombination of a NK1-antagonist and neostigmine, formulated together ina pharmaceutical composition, in admixture with a pharmaceutical carrieror vehicle; and instructions for use of the same for treatment ofsymptoms of muscle weakness associated with myasthenia gravis or anothermyasthenic syndrome in a mammalian subject in need thereof.

In another embodiment, a kit of the present invention is a kitcomprising pharmaceutical composition (a) comprising a NK1-antagonistand pharmaceutical composition (b) comprising neostigmine; andinstructions for use of the same for treatment of symptoms of muscleweakness associated with myasthenia gravis or another myasthenicsyndrome in a mammalian subject in need thereof.

The foregoing detailed description has been given for illustrationpurposes only, especially for purposes of clarity of understanding. Thedescription is not meant to be construed in a limiting sense. It will beapparent to those skilled in the art that certain changes andmodifications of the disclosed embodiments as well as alternativeembodiments may be practiced without departing from the spirit and scopeof the invention. It is contemplated that the appended claims will coverany such modifications or embodiments that fall within the scope of theinvention.

Examples

The ability of the NK1-antagonists for preventing the adverse effects oforally administered neostigmine bromide in humans is tested.

A Phase I study is conducted in human subjects receiving a single oraldose of neostigmine bromide with or without a single oral dose ofaprepitant hydrochloride dihydrate, as a representative NK1-antagonist.The study is a single center, single-blind, placebo-controlled study.

The objective of the study is to demonstrate that aprepitant safelyattenuates the gastro-intestinal side effects of neostigmine given indoses shown to be effective for the treatment of Myasthenia Gravis(Prostigmin® Prescribing Information).

To be enrolled in the study, participants are to meet the followinginclusion/exclusion criteria:

Key Inclusion Criteria

-   -   1. Male or female volunteers between the ages of 18 and 60 years        inclusive are required to be in good health, to refrain from        consuming xanthine, quinine and caffeine containing beverages,        and to refrain from prolonged intensive physical exercise during        the study conduct.    -   2. Subjects are to sign an informed consent form indicating that        they understand the purpose of and procedures for the study and        that they are willing to participate in the study and comply        with the study procedures and restrictions.    -   3. Subjects had to be in good health according to their medical        history including personal and family psychiatric history,        physical examination, ECG, vital signs, and laboratory tests. A        subject with a medical abnormality could be included only if the        investigator or designee considers that the abnormality does not        introduce significant additional risk to the subject's health or        interfere with study objectives.    -   4. Subjects had to be able to swallow multiple pills        simultaneously.

Key Exclusion Criteria

-   -   1. Any clinically relevant acute or chronic disease which could        interfere with the subjects' safety during the trial, expose        them to undue risk, or interfere with the study objectives.    -   2. History or presence of gastrointestinal, hepatic, or renal        disease or other condition known to interfere with the        absorption, distribution, metabolism or excretion of drugs.    -   3. History of substance abuse, known drug addiction, or positive        test for drugs of abuse or alcohol.    -   4. History of drug or other significant allergy.    -   5. ECG changes including QT interval prolongation and congenital        long QT syndrome. Electrolyte abnormalities (e.g., hypokalemia        or hypomagnesemia), congestive heart failure, bradyarrhythmias        or other conditions that lead to QT prolongation;    -   6. Treatment with centrally active drugs or those affecting        peripheral cholinergic transmission within 3 months of study        entry.    -   7. Smokers (except subjects who stopped smoking 1 year or more        before enrollment in the Study).    -   8. Excessive daily consumption of xanthines containing drinks        (i.e. >500 mg/day of caffeine).    -   9. Intake of an investigational drug within 30 days of study        entry.    -   Following enrollment in the study, participants will receive        single increasing oral doses of neostigmine, given once daily in        the morning. Once a subject reaches his/her first intolerable        dose (“FID-1”), upward dose escalation is discontinued. FID is        defined as:    -   (a) one episode of vomiting; or    -   (b) two episodes of retching; or    -   (c) one episode of severe nausea (Grade 3; defined as nausea        interfering with activities of daily living or inadequate oral        caloric or fluid intake; tube feeding, total parenteral        nutrition or hospitalization indicated) lasting more than 1        hour; or    -   (d) one episode of moderate diarrhea (Grade 2); defined as 4-6        stools more than at baseline); or    -   (e) three (3) consecutive episodes at every 4 hour ratings of        moderate nausea (Grade 2; defined as subjectively symptomatic,        but not interfering with activities of daily living).

When a subject reaches FID-1 on neostigmine alone, the subject is washedout for 2 to 7 days, and then receives their first intolerable dose(FID) of neostigmine plus a single oral dose of aprepitant, (in doses ofaprepitant up to 125 mg as necessary to prevent or attenuatedose-limiting gastro-intestinal adverse events) or aprepitant placebo.

On each study day, subjects are followed up for up to 8 hours for AEs,vital signs, and ECGs. In addition, a laboratory panel at screening andat the end of the study is taken.

The co-administration of an oral effective dose aprepitant withneostigmine prevents or attenuates the occurrence of gastro-intestinalAEs with neostigmine given in doses at least as high as or much higherthan the currently recommended efficacious dose of neostigmine for thetreatment of myasthenia gravis.

REFERENCES

-   Abicht et al, 2003 updated in 2014: Abicht A, Muller J S,    Lochmuller H. “Congenital Myasthenic Syndromes”. In: Pagon R A, Adam    M P, Ardinger H H, Wallace S E, Amemiya A, Bean U H, Bird T D,    Ledbetter N, Mefford H C, Smith R J H, Stephens K, editors.    GeneReviews® [Internet]. Seattle (Wash.): University of Washington,    Seattle; 1993-2016. 2003 May 9 [updated 2016 Jul. 14].-   Drachman, 2016: Drachman D B. “Myasthenia Gravis”. Semin Neurol.    2016; 36:419-424. Epub 2016 Sep. 23.-   Engel, 2012: Engel A G. “Congenital Myasthenic Syndromes in 2012”.    Curr. Neurol Neurosci Rep, 2012; 12:92-101.-   Gotterer and Li, 2016: Gotterer L, Li Y. “Maintenance    immunosuppression in myasthenia gravis”. J Neurol Sci. 2016;    369:294-302. Epub 2016 Aug. 28.-   Howard, 2015: Howard J F. “Clinical Overview of M G. Myasthenia    Gravis” Foundation of America; 2015.-   Lexell 1997: Lexell J. “Evidence for Nervous System Degeneration    with Advancing Age”. The Journal of Nutrition, Volume 127, Issue 5,    1 May 1997, Pages 10115-10135,    https://doi.Org/10.1093/jn/127.5.1011S.-   Makarious et al. 2017: Makarious D, Horwood K, Coward J. I. G.    “Myasthenia gravis: An emerging toxicity of immune checkpoint    inhibitors”. European J Cancer 82 (2017), 128-136.-   O'Grady et al, 2016: O'Grady G L, Verschuuren C, Yuen M, Webster R,    Menezes M, Fock J M, Pride N, Best H A, Benavides Damm T, Turner C,    Lek M, Engel A G, North K N, Clarke N F, MacArthur D G, Kamsteeg E    J, Cooper S T. “Variants in SLC18A3, vesicular acetylcholine    transporter, cause congenital myasthenic syndrome”. Neurology. 2016;    87: 1442-1448. Epub 2016 Sep. 2.-   Phillips and Vincent, 2016: Phillips W D, Vincent A. “Pathogenesis    of myasthenia gravis: update on disease types, models, and    mechanisms”. FIOOORes. 2016; 27:5.-   Shelton, 2016: Shelton G D. “Myasthenia gravis and congenital    myasthenic syndromes in dogs and cats: A history and mini-review”.    Neuromuscul Disord. 2016; 26: 331-334. Epub 2016 Mar. 10.-   Smith and Lee, 2017: Smith S V, Lee A G. “Update on Ocular    Myasthenia Gravis”. Neurol Clin. 2017; 35: 115-123.

EXEMPLARY ASPECTS

The following is a non-limiting list of exemplary aspects of theinvention, presented as a listing of embodiments, which is intended tohighlight and illustrate various facets of the invention. In thisrespect, the invention provides, among other things—

1. A method for safely improving the conditions of a mammal sufferingfrom symptoms of muscle weakness associated with MG or anothermyasthenic syndrome, comprising chronically administering to said mammala NK1-antagonist in combination with neostigmine.

2. The method of aspect 1, wherein said neostigmine is neostigminebromide or neostigmine methylsulfate.

3. The method of aspect 1, wherein said NK1-antagonist is aprepitant ora pharmaceutically acceptable salt or solvate or prodrug thereof.

4. The method of aspect 1, wherein said NK1-antagonist is administeredto said mammal at a single oral or subcutaneous dose of from 1 μg to 600mg/day.

5. The method of aspect 1, wherein said neostigmine in said combinationis administered to said mammal at a daily dose, for any administrationroute and including titration doses, equivalent to from 0.2 mg to 1500mg of neostigmine bromide or neostigmine methylsulfate.

6. The method of aspect 5, wherein said neostigmine is administered tosaid mammal at a maximally effective parenteral daily dose, byintravenous 24 h-infusion, equivalent to from 10 mg to 500 mg ofneostigmine methylsulfate.

7. The method of aspect 5, wherein said neostigmine is administered tosaid mammal at a maximally effective oral daily dose equivalent to from375 mg to 1500 mg of neostigmine bromide.

8. The method according to aspect 1, wherein said neostigmine in saidcombination is administered to said mammal in a unit form, for anyadministration route and including titration doses per unit form,comprising said neostigmine in an amount per unit form equivalent tofrom 0.09 mg to 500 mg of neostigmine bromide or neostigminemethylsulfate.

9. The method of aspect 8, wherein said neostigmine is administered tosaid mammal in a unit form for continuous subcutaneous infusioncomprising said neostigmine in an amount per said unit form equivalentto from 0.09 mg to 500 mg of neostigmine methylsulfate.

10. The method of aspect 8, wherein said neostigmine is administered tosaid mammal in a unit form for oral administration comprising saidneostigmine in an amount per said unit form equivalent to from 15 mg to200 mg of neostigmine bromide.

11. The method of aspect 3, wherein said prodrug of said aprepitant isfosaprepitant.

12. The method of aspect 1, wherein said mammal is suffering frommyasthenia gravis.

13. The method of aspect 12, wherein the mammal is a human, dog or cat.

14. A pharmaceutical combination comprising a NK1-antagonist andneostigmine.

15. A pharmaceutical composition comprising a NK1-antagonist andneostigmine.

16. The composition of aspect 15, further comprising a pharmaceuticallyacceptable carrier or vehicle.

17. A kit comprising the pharmaceutical combination of aspect 14, or thepharmaceutical composition of aspect 15, and instructions for treatmentof symptoms of muscle weakness associated with myasthenia gravis oranother myasthenic syndrome.

18. The pharmaceutical combination of aspect 14, or pharmaceuticalcomposition of claim 15, wherein said NK1-antagonist is present at adaily dose of from 1 μg to 600 mg and said neostigmine is present at adaily dose equivalent to from 0.2 mg to 1500 mg of neostigmine bromideor methylsulfate.

What is claimed is:
 1. A method for safely improving the conditions of amammal suffering from symptoms of muscle weakness associated with MG oranother myasthenic syndrome, comprising chronically administering tosaid mammal a NK1-antagonist in combination with 0.2 mg to 1500 mg ofneostigmine.
 2. The method of claim 1, wherein said mammal is sufferingfrom myasthenia gravis.
 3. The method of claim 2, wherein the mammal isa human.
 4. The method of claim 3, wherein said NK1-antagonist isadministered to said human at a single oral or subcutaneous dose of from1 μg to 600 mg/day.
 5. The method of claim 4, wherein saidNK1-antagonist is aprepitant or a pharmaceutically acceptable salt orsolvate or prodrug thereof.
 6. The method of claim 4, wherein saidneostigmine in said combination is administered to said human at a dailydose, for any administration route and including titration doses,equivalent to from 0.2 mg to 1500 mg of neostigmine bromide orneostigmine methylsulfate.
 7. The method of claim 4, wherein saidneostigmine is administered to said human at a maximally effectiveparenteral daily dose, by intravenous 24 h-infusion, equivalent to from10 mg to 500 mg of neostigmine methylsulfate.
 8. The method of claim 4,wherein said neostigmine is administered to said human at a maximallyeffective oral daily dose equivalent to from 375 mg to 1500 mg ofneostigmine bromide.
 9. The method according to claim 4, wherein saidneostigmine in said combination is administered to said human in a unitform, for any administration route and including titration doses perunit form, comprising said neostigmine in an amount per unit formequivalent to from 0.09 mg to 500 mg of neostigmine bromide orneostigmine methylsulfate.
 10. The method of claim 4, wherein saidneostigmine is administered to said human in a unit form for oraladministration comprising said neostigmine in an amount per said unitform equivalent to from 15 mg to 200 mg of neostigmine bromide.
 11. Themethod of claim 5, wherein said prodrug of said aprepitant isfosaprepitant.
 12. A pharmaceutical combination comprising aNK1-antagonist and neostigmine and a pharmaceutically acceptable carrieror vehicle, wherein said NK1-antagonist is present at a daily dose offrom 1 μg to 600 mg and said neostigmine is present at a daily doseequivalent to from 0.2 mg to 1500 mg of neostigmine bromide ormethylsulfate.
 13. The pharmaceutical combination of claim 12, whereinsaid NK1-antagonist is aprepitant or a pharmaceutically acceptable saltor solvate or prodrug thereof.
 14. The pharmaceutical combination ofclaim 13, wherein said prodrug of said aprepitant is fosaprepitant.